Providers Treat Patient with Multiple Gunshot Wounds

Difficult airway case presents challenges

 

 
 
 

Steven R. Allen, MD | From the June 2012 Issue | Tuesday, June 5, 2012


A fire rescue crew responded to a call that described someone who was reportedly “shot in the chest.” The scene was secured by law enforcement before EMS arrival. On arrival at the scene, EMS providers discovered a patient reportedly in his 30s who was unresponsive in the supine position with multiple gunshot wounds to his chest and extremities.

Assessment & Treatment
Providers learned that the patient was allegedly in an altercation with another man outside a bar. The conflict became violent, and the patient sustained multiple gunshots to his chest and right thigh. The patient was unresponsive with labored breathing and unstable vital signs. He did not present with signs of external exsanguinations. In addition to his hemodynamic instability, the patient was noted to have crepitus over his left chest.
The patient was unresponsive and had a Glasgow Coma Scale (GCS) score of 3. He was unable to protect his airway, so providers attempted an endotracheal intubation (ETI) with a 7-0 endotracheal tube (ETT) by the first-arriving EMS crew. However, this was aborted because of the patient’s strong gag reflex. The patient was transported to the landing zone, where a PennStar flight crew performed rapid sequence intubation. On the first attempt, the patient was noted to have a very swollen airway with poor visualization of airway landmarks. After two failed attempts with standard laryngoscopy, the providers successfully placed the ETT using the King Vision video laryngoscope blade.

Successful ETI was confirmed with end-tidal carbon dioxide (EtCO2), and breath sounds were confirmed bilaterally. Providers noted subcutaneous emphysema, which was demonstrated with palpable crepitus over the patient’s left chest and hemodynamic instability, which prompted needle decompression of the left chest.

The patient’s vital signs improved with these interventions. A rapid evaluation of his wounds at the scene identified a single wound just inferior to his left clavicle and multiple wounds to his left thigh, all of which weren’t actively bleeding. A C-collar was placed on the patient, and he was transferred to the flight stretcher and transported to the trauma center by an air medical crew.

Trauma Center Care
On arrival at the trauma center, the trauma team performed the primary survey and placed the patient on the monitor to measure vital signs. They recorded a heart rate of 106 beats per minute; blood pressure of 79/48 mmHg and EtCO2 of 31 mmHg. During the primary survey, the trauma team used direct laryngoscopy and color change capnography during their primary assessment to confirm the patient’s airway was in the correct position.

Because the patient underwent needle decompression of his left chest, a left tube thoracostomy was immediately placed in the standard fashion without a return of air or blood. The patient was sedated after intubation and remained with a GCS of 3. Although movement of extremities couldn’t be assessed on this evaluation due to sedation, the patient presented with priapism, which is concerning for a spinal cord injury.

The wounds were again identified and marked, and plain radiographs were obtained to assess the trajectory. A single wound was identified over the left chest just inferior to the clavicle with a primary bullet fragment in the midline of the neck. Two wounds were identified on the left thigh. There was no active bleeding from the wounds.

The patient was transported emergently to undergo a computed tomography (CT) scan with an angiogram of the neck and left lower extremity to assess for vascular injuries of the neck and injured leg, respectively. Cessation of blood flow was recorded in the left common carotid artery with reconstitution above the bifurcation. The CT angiogram of his left leg was normal. The patient was moved emergently to the operating room for exploration of his neck to identify and repair the injury to the carotid artery and assess for injuries to the trachea, esophagus and surrounding structures.

The patient underwent a median sternotomy that was extended up onto the neck to better expose the carotid artery. A destructive injury of the common carotid artery at the level of the clavicle was identified. The carotid artery was controlled in the chest and repaired with a saphenous vein interposition graft. The trachea was assessed and found to be uninjured. An endoscope identified a small area of ecchymosis on the esophageal wall. However, because of the presumed injury and the patient’s inability to eat for a prolonged period of time, a percutaneous feeding tube was placed in his stomach.

The patient was found to have a complete spinal cord transection at C-6 with associated quadriplegia. He suffered ventilator-dependent respiratory failure and required a tracheostomy for prolonged ventilator support. He was weaned from the ventilator and discharged to an inpatient rehabilitation center, where he continues to improve.


Discussion
ETI is the standard of care for definitive airway management. Success rates of ETI in the prehospital setting vary significantly in the literature. The presence of a difficult airway in any setting is a life-threatening scenario, which requires significant skill and forethought with other alternatives in the event that standard strategies fail. Multiple reports have demonstrated higher incidence of unanticipated difficult intubations in the prehospital setting compared to those in the operating room.

Although the incidence of difficult intubation is only 2% in elective anesthesia care, the incidence in the prehospital environment approaches 10%.1 Management of an airway in the prehospital setting may be difficult for many reasons:

>> The patient is in extremis, hemodynamically unstable or uncooperative;
>> The patient has particular injury patterns, such as fractures and trauma to the face and neck with associated bleeding and swelling in and around the neck and orpharynx; or
>> The patient has emesis and aspiration.

Although controversy surrounds the use of ETI in the prehospital setting, there’s also a body of evidence that demonstrates the benefits in patient outcomes with prehospital intubation in patients with traumatic brain injury, cardiac arrest and risk for loss of airway patency or aspiration.2 Prehospital providers must weigh the risks and benefits to the establishment of an artificial airway.

Complications related to ETI include unrecognized esophageal intubation with associated hypoxia and hypoventilation, oropharyngeal or tracheal injury or even hyperventilation, which may lead to cerebral ischemia.1 With these risks in mind, providers need to consider the risks of not establishing a definitive airway prior to transport of the patient. In the case presented here, in which the patient had labored breathing and increased swelling of the patient’s neck, a delay in airway control could’ve been a mortal decision because loss of airway patency
was imminent.

Multiple airway management algorithms have been established. One study defines a difficult airway as a failure of tracheal intubation after a single attempt in a patient with a Cormack-Lehane class IV airway or two failed attempts in a patient with a Cormack-Lehane class of III or less.(2)
Most recently, a variety of video laryngoscopes (VLs) have been advocated to facilitate successful ETI in the case of a difficult airway. The proposed benefit of using a VL is improved visualization of anatomy with improved graphics on the monitor in contrast to the minimal view one may see on a traditional laryngoscope—especially in dark, austere environments. Early studies have demonstrated quicker intubation and improved success rates in ETI with a VLs when used by medical students, nurses and paramedics.(1,3)

However, these data are preliminary and haven’t been reproduced. Other studies have demonstrated the advantages of VLs in patients with difficult anatomy compared with a Macintosh laryngoscope. Although video-assisted intubation may have its advantages, it’s not
recommended as a first-line technique in standard intubations. (3)

Conclusion
Penetrating wounds to the chest and neck may present EMS providers with significant challenges related to airway management. It’s important to use sound judgment whenever a case requires definitive airway management because it’s key to act quickly to secure the airway in cases involving traumatic brain injury or impending airway loss.
A difficult airway may be encountered in those patients with penetrating injuries to the head, neck or chest.

The provider must be skilled at ETI. In the case that standard intubation is unsuccessful, the provider must be able to use other means to establish the airway, which may include a bougie, laryngeal mask airway, video laryngoscopy or even a surgical airway. This article originally appeared in June 2012 JEMS as "Difficult Airway: Providers treat patient with multiple gunshot wounds."

References
1. Butchart AG, Tjen C, Garg A, et al. Paramedic laryngoscopy in the simulated difficult airway: Comparison of the Venner A.P. Advance and GlideScope Ranger video laryngoscopes. Acad Emerg Med. 2011;18(7):692–698.
2. Warner KJ, Sharar SR, Copass MK, et al. Prehospital management of the difficult airway: A prospective cohort study. J Emerg Med. 2009;36(3):257–265.
3. Dupanovic M, Fox H, Kovac A. Management of the airway in multitrauma. Curr Opin Anaesthesiol. 2010;32(2):276–282.

Resources
>> Combes X, Jabre P, Margenet A, et al. Unanticipated difficult airway management in the prehospital emergency setting: Prospective validation of an algorithm. Anesthesiology. 2011;114(1):105–110.




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Related Topics: Case of the Month, Steve Allen, Kayla Conover, gunshot, Jems Case of the Month

 

Steven R. Allen, MDSteven R. Allen, MD, is an assistant professor of surgery at the University of Pennsylvania in Philadelphia. He’s board certified in surgery and surgical critical care and practices as a trauma surgeon and surgical intensivist. He can be contacted via e-mail at Steve.Allen@uphs.upenn.edu.

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